Covid 19

Name * Age * Sex * Male Female Other Mobile * Address * Marital Status * Education * Referred by * Case *

Example: Mild symptoms, awaiting test results, exposed to a confirmed case

Current Symptoms *

Example: Fever, cough, headache, fatigue

Since how many days are you suffering? * Any reason or trigger could have initiated it? *

Example: Recently traveled, contact with a symptomatic person

Fever Details

How did it start? *

Example: Sudden onset or gradual increase

Where did chilliness start in your body? *

Example: Hands, feet, or overall body

Direction of Chilliness *

Example: Spreading, moving towards core

What makes the chilliness worse? *

Example: Exposure to cold air, lack of clothing

Other symptoms with fever *

Example: Headache, muscle aches, fatigue

Cough Details

What increases the cough? *

Example: Physical activity, cold air, laughter

What decreases the cough? *

Example: Warm drinks, cough syrup

Type of Cough *

Example: Dry, wet, persistent

Expectoration *

Example: Mucus production, consistency

Quantity *

Example: Amount per day (e.g., 3 times, a lot)

Color *

Example: Clear, yellow, green

Quality *

Example: Thick, thin

Other Symptoms

Appetite *

Example: Increased, decreased, normal

Altered Taste *

Example: Loss, metallic taste

Nose Symptoms *

Example: Congestion, runny nose

Thirst *

Example: Increased thirst, no change

Urine *

Example: Color, frequency

Stools *

Example: Consistency, color

Perspiration *

Example: Sweating increased, decreased

Sleep *

Example: Disturbed, uninterrupted

Termals *

Example: Feeling hot or cold

Mind and Mood State *

Example: Anxious, calm, stressed

Investigation Reports (if applicable) *

Example: Blood test results, imaging reports

COVID Report *

Example: Positive, negative, awaiting results

COVID Questionnaire Form

Current Symptoms *

Fever Details

Cough Details

Other Symptoms